This Angel is pissed off. I'm Nurse Anne and I work on large general medical ward in the NHS. These are the wards with the most issues surrounding nursing care. The problems are mostly down to intentional understaffing by hospital chiefs that result in a lack of real nurses on the wards.
"The martyr sacrifices themselves entirely in vain. Or rather not in vain, for they merely make the selfish more selfish, the lazy more lazy and the narrow more narrow"-Florence Nightengale

Tuesday, 27 October 2009

Productive ward. Again. Kill me please.

Apparently the ward would run as smooth as silk if only nurses understood how to tidy cupboards and work more efficiently.

The physical ward layout (appalling), the chaos, the constant interruptions and the massive lack of qualified staff make the idea of working efficiently a joke. The closest we can come to being efficient is taking dangerous short cuts just to ensure that we can actually assess everyone and get all the drugs out and administered without a fatality. All registered nurses are forced to do this on a daily basis because of the working conditions that they cannot control. Anyone who says that this isn't true is a liar.

Even if we could tidy and reorganise the cupboards we would still be up and down that ward constantly, wasting precious minutes. The thing needs to be redesigned and rebuilt to be truly workable. Half our supplies are always missing and require the ward staff to abandon patient care to obtain things constantly throughout the shift. Productive ward isn't going to fix this mess, it just puts more culpability onto the nurses. Pharmacy, and equipment /central supply are 9-5 Monday to Friday. And even during 9-5 they are fucking useless. They cause is more work than any patient ever did. Their worldview is that the lone RN on a ward with 20 something patients is there to make their job easier. God how I hate them.

Let me give you an example of something that happens about 100 times during an 8 hour shift. The lab calls me at 4PM and tells me that my patient's most recent blood results are barely compatible with life. My job is to inform the doctor who is covering. He orders a medicine. Of course pharmacy won't allow us to keep it in stock. To get the medicine I have to ring pharmacy, leave a message, wait for them to call back and then argue with them for about 15 minutes. They are pissy because they are supposed to finish work for the day at 5PM. They stomp their feet and say that they will not bring said drug to the ward. I have to walk the written doctor's order for the drug to pharmacy.

I get there and they ignore me for another 15 minutes while I bang on the glass. I. am. Serious.

They say that they will ring me as soon as the drug is ready. I reiterate the fact that I need this drug NOW. I cannot sit there however. I have many other things going on with my other patients that are almost as high a priority.. 30 minutes sat in pharmacy could seriously harm my patients who are now nurseless. Pharmacy promises me that they will bring the drug to me asap. If I send a care assistant rather than go down there myself it is bound to get all fucked up. 99% of the time we cannot get through to them via phone as they have it permanently on voicemail.

Back to the ward now. I need a special pump to deliver this med that we also are not allowed to keep on the ward as per central supply's dumbassness. I call central supply. A grumpy man who is obviously eating something chewy answers the phone. I tell him what I need. Very slowly he responds with "Well you will just have to come down here and get it".

But I cannot. I am hoping to get this drug administered ASAP as soon as that slut from pharmacy gets her ass here (and she had better hurry I swear to god).

I tell Dick from Central Supply that I am in no position to leave the ward (yet again) and my care assistant is trying to stop my alcohol detoxer from attacking the other patients (so am I while I am on the phone).

He chews whatever the fuck he is eating and slowly responds with "sigh sigh siiiigghhh. I will bring it up if I must. You had better go around your ward and find every piece of equipment that belongs to central supply. Clean it and label it before I get there and put it on a trolley so I can bring it back with me. I don't wanna make two trips. I'll be there in 15 minutes so have it ready for then."

Yeah right Dick. I am chasing pharmacy right now. There is now only myself and a care assistant on the ward. The other RN is now in recovery picking up her post op patient and the other care assistant had to escort a dementia patient to the CT scanner because the staff down there don't want to deal with it. I have a patient who has blood results that show that she needs this drug infusing via this particular pump NOW. I have an alcohol detoxer who is beating the care assistant, trying to beat other patients and myself and we cannot get her doctor to come up here and prescribe sedation. I have 20 other patients as well. I had over 15 IV antibiotics due in the last hour that I haven't even begun to mix. I have a que of angry relatives that want to know exactly what it is we are doing for their loved one. I will certainly be ignoring Dick from Central Supply's request.

And pharmacy still is not here. I ring them. I get voicemail. I can't go down there and neither can my care assistant.You leave one person on the ward and a crash occurs you are fired.

Now the doctor who prescribed the drug for the patient with scary blood results is on the ward. He looks at his patient. His face turns the colour of a tomato. He glares at me. "Why the hell hasn't the drug I ordered been started yet? What the hell are you doing? Do you not understand that it is priority?" he screams.

Yes I do doc. But I cannot give what I don't have or pull syringe pumps out of my ass. I have already been ignoring many sick people over the last hour trying to pull this together. By the way...do you see that patient over there beating the healthcare assistant? See the scratches on my arm? Her doctor is tied up somewhere...will you prescribe her some sedation? Benzos not appropriate I know...how about haldol...anything?

"No. Not my patient. Get the anti -scary- blood- results- drug up now and call security for your combative patient."

The he left. We did call security actually. Those are the porters. They informed us that they are too busy.

OMG where the fuck is that slut from pharmacy. Their phone is still engaged. I cannot leave the ward. Dick from central supply showed up with the pump, took one look at the alcohol detoxer who was licking the floor and trying to hit anyone who came near and left quickly.

Now I have my pump. But where oh were is that slut from pharmacy.

I run to the end of the ward and peer down the hallway. There is the slut from pharmacy. She is holding what looks like the box containing the drug I need. She is stood talking with her friend from medical records that she has obviously run into on her way here. I walk over to her. I grab the box out of her hands. "Is this for ward R" I say. "Yes" she says whilst looking shocked that I just grabbed something out of her hands roughly. And off I go back to my ward whilst shouting "I needed this an hour ago".

"Those nurses really have an attitude don't they" she says to her friend.

Now I move at the speed o0f light getting the drug out mixed, ,measured, drawn up and doing my maths calculations. My other RN is back from theatre and quickly she checks my arithmetic. I get the drug up and grab a set of obs on my patient. Finally after over an hour of bullshit she is getting the treatment that the doctor ordered. What if I had dropped the ball on this an hour ago? What if I hadn't notified her doctor of her blood results or stayed on pharmacy's ass, multitasked, moved quickly and ignored my other patients calls for help to get this patient her treatment? The brilliant doctor and his brilliant treatment orders go nowhere if they are not implemented. And implementation of treatments is totally the domain of the registered nurses. It takes knowledge and you have to fight! Diagnosing and prescribing (the doctors domain) is only the first step of a very complex process of caring for hospital patients.

Now I brace myself to settle down this detoxer (she has already taken a chunk out of my upper arm) so we can get back to caring for all the patients...but in 10 minutes it will all start again and we will be looking for things.

This is how bad things are during 9-5 hours. You should see what it is like trying to get what you need out of hours.

But they want us to understand that if we tidy cupboards on the ward all will be well. Productive ward will not in any way shape or form deal with the bullshit from central supply and pharmacy. It will not address the fact that we are running these wards with so little staff that we can barely address 1% of what we should be doing. But this is their "solution" to problems that they do not understand.

Now that productive ward is back in full swing our ward sister has been forced to put a cork board up at the nurse's station. On it she has been forced to put little motivational messages. We are supposed to add to these messages by writing our feelings onto the board. The messages say things like:

Releasing time to care: I will understand that I am here for the patients

Working more efficiently so every shift will be a joy!.

Helping the ward to be more organised so that we can spend time with the patients.Every single member of ward staff is supposed to grab a colourful marker, some nice paper and add their happy visions about the productive ward to this board. I haven't added mine yet. Do you guys have any suggestions for me?

I was thinking about stealing this from mental nurse and posting it on the happy happy joy joy board.

25 comments:

I've seen the literature sitting on our "leaders" desk, I had a quick look, that was enough, I was looking for the nearest shredder! Just more timewasting crap. Our supplies only come every 2 weeks now, and they always seem to miss half of the order. Our pharmacy - the same.

Couldn't agree more with everything you say. 1 RN to 22 patients last Monday afternoon on my ward (I'm a consultant) - how many of the possible 8 discharges could she help organise then (chase pharmacy for TTOs, organise transport, ring relatives)? I had to go to clinic so told her not to worry if none of them went home, just keep everyone alive and we'll sort it out tomorrow. Every consultant in my department has been telling management for at least 8 years that their nursing establishment is wrong and only works if there are no bank nurses and no sick patients! Now I am being forced to a workshop to discuss how to speed up discharge without spending any money or staffing the ward properly with nurses. Your blog keeps me going when I despair

I'm an A&E nurse. I took a poorly patient to the ward today, and found 1 RN there, looking after 30 patients. The Other RN was away grabbing food mid-way through her 14 hr shift. The sole RN was having to stay by the bedside of a confused patient thhrowing herself over the cotsides on to the floor. I felt like shit having to dump 'another' patient on her, especially as he was poorly. Its riduculous, cos if the shit hits the fan an someone dies, that poor, lone RN will get the blame. Disgusting NHS. Disgusting.

...and it all costs like 50 million. It would be more cost effective and have a higher success rate to increase the ratio of RN's but noooooo.

Soon I will be the sole rn for twenty something patients. I will have 4 untrained brand new care assistants who are mostly teenagers. Therefore I will be carrying everything myself. Just doing all the drugs etc on all those people will be all encompassing. The first morning drug round will take 3.5 hours and in that time I won't be able to focus on anything else.

The untrained little care assistants will be completely taking over the actual care side (which they will screw up because they have no idea). They won't remember to document fluid balance, won't notice changes in condition, they will "forget" to do blood sugars and think it funny. I am responsible for any fuck ups they make.

Yet I am over such a large area I cannot supervise, I will be up to my eye balls in meds, assessments, interruptions, rounds, relative enquiries. I won't ever go more than a minute without interruption and getting pulled in another direction.

But management will say something stupid like "but there are 5 of you, what are you complaining about?". And the fucking visitors will waltz in there and say "there are 5 nurses here, why are patients waiting an hour for pain meds"

It makes me sick. Productive ward will be a fail. It will always be a fail until they realise that the wards need to be staffed primarily with RN's who have a small group of patients each as well as a charge nurse coordinating. Until then every scheme will be a waste of money and it will be fail fail fail.

Legislate safe ratios and they (RN's) will come. When California mandated ratios ordering the hospitals to have no more than 5 patients to every bedside RN on a ward like mine the hospitals cried out "but there aren't enough nurses to do this! we will have to shut wards!"

The ratios were forced on them despite their stupid worries. Thousands upon thousands of registered nurses (like 80,000 in the first year) came back to bedside nursing once the ratios went into law. And even though they are paying many more nurses they are saving more money than they are spending because of the reduction in complications, errors, deaths, and quicker discharges.

This has been the result everywhere that has ratio laws. Hospitals with a higher proportion of highly educated RN's at the bedside actually have lower costs than hospitals who staff their wards with mostly untrained kiddies.

I'm so glad to be retired(only just) and was comtemplating doing some bank work, but have had a taste of that in the past - the only RN for 12 heavily dependent patients - No thanks.The Productive Ward deserves an award for the top useless idea. Elio

You are right the health is very important, so nurses should find a quickly solution for these problems, they have to improve the health cares because a simply mistake will be an awful result. So organize the important things first.

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This blog is a joke and I sure as hell hope that neither myself or my family end up in your care.You can change the way you work, it just involves some determination. Or if you prefer to stick your head in the sand, then I hope you get sacked soon...if you have not been to a disciplinary already.Thank god there are staff out there who strive to make every day better for our patients, instead of just moaning about anything.Less moaning, more 'doing'!!!!!!Create a positive, proactive ward, not one waiting for accidents to happen.

In an atmosphere if universal deceit telling the truth is a revolutionary act. George Orwell.

Why has Nursing Care Deteriorated

Good nurses are failing every day to provide their patients with a decent standard of care. You want to know what has happened? Read this book and understand that similiar things have happened in the UK. Similiar causes, similiar consequences. And remember this. The failings in care have nothing to do with educated nurses or nurses who don't care. We need more well educated nurses on the wards rather than intentional short staffing by management.

About Me

I am a university educated registered nurse. We had a hell of a lot of hands on practice as well as our academic courses. The only people who say that you don't need a brain or an education to be an RN are the people who do not have any direct experience of nursing in acute care on today's wards. I have yet to meet a nurse who thinks that she is above providing basic care. I work with nurses who are completely unable to provide basic care due to ward conditions.
I have lived and worked in 3 countries and have seen more similarities than differences. I have been a qualified nurse for nearly 15 years. I never used to use foul language until working on the wards got to me. It's a mess everywhere, not just the NHS.
Hospital management is slashing the numbers of staff on the ward whilst filling us up with more patients than we can handle... patients who are increasingly frail. After an 8-14 hour shift without stopping once we have still barely scratched the surface of being able to do what we need to do for our patients.

Quotes of Interest. Education of Nurses.

Hospitals with higher proportions of baccalaureate-prepared nurses tended to have lower 30-day mortality rates. Our findings indicated that a 10% increase in the proportion of baccalaureate prepared nurses was associated with 9 fewer deaths for every 1,000 discharged patients."...Journal of advanced nursing 2007

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania identified a clear link between higher levels of nursing education and better patient outcomes. This extensive study found that surgical patients have a "substantial survival advantage" if treated in hospitals with higher proportions of nurses educated at the baccalaureate or higher degree level.

THIS MEANS WE NEED WELL EDUCATED NURSES AT THE BEDSIDE NOT IN ADVANCED ROLES

Dr. Linda Aiken and her colleagues at the University of Pennsylvania's Center for Health Outcomes and Policy Research found that patients experienced significantly lower mortality and failure to rescue rates in hospitals where more highly educated nurses are providing direct patient care.

Evidence shows that nursing education level is a factor in patient safety and quality of care. As cited in the report When Care Becomes a Burden released by the Milbank Memorial Fund in 2001, two separate studies conducted in 1996 - one by the state of New York and one by the state of Texas - clearly show that significantly higher levels of medication errors and procedural violations are committed by nurses prepared at the associate degree and diploma levels as compared with the baccalaureate level.

Registered Nurse Staffing Ratios

International Council of Nurses Fact Sheet:

In a given unit the optimal workload for a registered nurse was four patients. Increasing the workload to 6 resulted in patients being 14% more likely to die within 30 days of admission.

A workload of 8 patients versus 4 was associated with a 31% increase in mortality. (In the NHS RN's each have anywhere from 10-35 patients per RN. It doesn't need to be this way..Anne)

Registered Nurses in NHS hospitals usually have between 10 and 30+ patients each on general wards.

Earlier in the year, the New England Journal of Medicine published results from another study of similar genre reported by a different group of nurse researchers. In that paper, Needleman et al3 examined whether different levels of nurse staffing are related to a patient’s risk of developing complications or of dying. Data from more than 5 million medical patient discharges and more than 1.1 million surgical patient discharges from 799 hospitals in 11 different states revealed that patients receiving more care from RNs (compared to licensed practical nurses and nurses’ aides) and those receiving the most hours of care per day from RNs experienced fewer complications and lower mortality rates than those who received more of their care from licensed practical nurses and/or aides. Specifically for medical patients, those who received more hours per day of care from an RN and/or those who had a greater proportions of their care provided by RNs experienced statistically significant shorter length of stay and lower complication rates (urinary tract infections, gastrointestinal bleeding, pneumonia, cardiac arrest, or shock), as well as fewer deaths from these and other (sepsis, deep vein thrombosis) complications

•Lower levels of hospital registered nurse staffing are associated with more adverse outcomes such as Pneumonia, pressure sores and death.
•Patients have higher acuity, yet the skill levels of the nursing staff have declined as hospitals replace RN's with untrained carers.
•Higher acuity patients and the added responsibilities that come with them increase the registered nurse workload.
•Avoidable adverse outcomes such as pneumonia can raise treatment costs by up to $28,000.
•Hiring more RNs does not decrease profits. (Hospital bosses don't understand this. They think that they will save money by shedding real nurses in favour of carers and assistants. The damage done to the patients as a result of this costs more moneyi.e expensive deaths, complications,and lawsuits, and complaints....Anne)

Disclaimer

I know I swear too much. I am truly very sorry if you are offended. Please do not visit my blog if foul language upsets you. I want to help people. That is why I started this blog and that is why I became a Nurse. I won't run away from Nursing just yet. I want to stick around and make things better. I don't want the nurses caring for me when I am sick working in the same conditions that I am. Of course this is all just a figmant of my imagination anyway and I am not even in this reality. Or am I?Any opinions expressed in my posts are mine and mine alone and do not represent the viewpoint of the NHS, the RCN, God, or anyone else.